Saturday, September 1, 2007

URGENT BULLETIN FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION AND THE OFFICE OF PUBLIC AFFAIRS OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

FOR ALL HOSPITAL AND HEALTH PROFESSIONALS; PROFESSIONALS IN THE BIOLOGICAL SCIENCES

OVERVIEW OF EPIDEMIC DISEASE CONTINENTAL UNITED STATES

RABIES EVANGEL (REV)

Background

The rabies evangel virus (REV) is a species of rabies virus currently threatening to reach worldwide epidemic proportions. While rabies evangel in itself is no more virulent, nor difficult to prevent than other species of rabies and, in fact, has considerably lower mortality, it afflicts the infected person with sensations of religious euphoria, mania, and hallucinations and its infection is associated with deliberate, conscious attempts to spread the disease. Whether this latter behavior is a direct consequence of the infection or a mass disorder based on existing human religious beliefs and practices is unclear. It is undeniable, however, that the rapid spread of the disease and its possible future as an endemic if not universal infection for the worldwide human population, originates in the unique adaptation of this pathogen to benefit from the conscious efforts of human intelligence, technology and behavior to directly forward its propagation.

Causes, incidence, risk factors

Like earlier species of rabies, rabies evangel (REV) is spread by the saliva of an infected organism entering the bloodstream, usually through a bite, broken skin or through some kinds of sexual contact. The incubation period from inoculation to illness is about 7 days. The virus ultimately ends up in the brain, where it causes swelling (encephalitis). Unlike earlier forms of rabies, the encephalitis subsides and is restricted to certain parts of the brain, resulting in low mortality and sensations of euphoria, often with religious or schizoid ideation with marked manic behavior.

Though the disease remains zoonotic (other animals such as dogs, raccoons, rats, bats may carry the disease) most cases of REV are caused by deliberate human bites, injuries or other blood letting, or through biological weapons deliberately engineered by afflicted individuals to spread the disease.

The disease is now worldwide, reported on all continents except Antarctica with high concentrations in the American South, Middle East, Afghanistan and Pakistan. Particularly at risk are health and public safety workers, as there is an active attempt on the part of infected individuals to actively spread the disease. Only individuals in remote, inaccessible areas with little or no human population, are not at high risk for this infection.

Overall susceptibility to the disease seems to vary with the size of the inoculation, degree and severity of the bite or infected wound, and the proximity of the latter to the central nervous system.

Pathophysiology

Rabies evangel, like previously known forms of rabies, is a Lyssavirus of the family Rhabdoviridae, an RNA virus. It is shaped like a bullet with a lipoprotein envelope covered with knob like spikes of glycoprotein.

It is these spikes of glycoprotein that attach to the nicotinic acetylcholine receptor of skeletal muscle where it reproduces; from there the virus has entry to the nervous system through unmyelinated sensory and motor terminals.

Once it has entered into the nervous system, the virus is effectively shielded from the immune system, spreading to the spinal column and through peripheral nerves to the skin, intestines and salivary glands, where it forms an infectious reservoir for biting.

Unlike previous known forms of rabies, however, REV is not indiscriminate in its action; after a brief period of cerebral swelling, it seems to favor a region of the frontal lobes previously associated with religious experiences[1]. Though the exact mechanism is unclear, it is believed that the virus, through its reproduction through infected tissues or some other means, stimulates the frontal lobes in such a way as to give the afflicted sensations and experiences typical of religious euphoria or psychedelic agents such as psilocybin (Griffiths, 2006).

It is important to stress at this point that none of the organized intentional behavior resulting from such experiences appears to be directly in any way created by the virus itself. Rather, it seems to be an independent human cultural behavioral response to the experience, including the apparent desire to deliberately spread the disease to uninfected individuals. This behavior, however, is quite beneficial to the propagation of the virus (discussed below).

Though the virus seems specific in attacking the frontal lobes, other parts of the brain are also often infected, leading to the hallucinations, agitation, motor difficulties and anxiety typical of earlier forms of rabies.

However, unlike previous forms of rabies, the encephalitis never progresses to become life threatening; rather this species of rabies virus seems to have reached a kind of equilibrium with its human hosts. While not asymptomatic and far from a harmless, carriers are able to function and complete complex tasks, including deliberate attempts to infect others.

Symptoms

• Pain and swelling at site of infection (usually a bite)• Increased sensitivity at site of infection• Initial high fevers with rapidly progressing encephalitis• Myoclonus (popularly referred to “trembling in the sight of god”)• Increased lacrimation (popularly referred to as the “tears of witness”)• Hypersalivation• Religious Euphoria/Mania• Schizoid ideation• Hallucinations• Compulsion to infect uninfected individuals

Communication

Epidemiologists have long understood that the greatest problem in disease control, more than any the particular virulence factors that aid the pathogen, is the human behavior that abets and enables its spread. HIV, for instance, is actually quite difficult to transmit other than through sexual contact or blood contamination, yet human frailty meets the disease more than halfway; meticillin-resistant Staphylococcus aureus is owes its spread, among other things, to simple nose picking; malaria afflicts hundreds of millions because people find it difficult to use mosquito netting properly.

This familiar problem reaches an new and unique degree with rabies evangel, in that its spread is not an inadvertent result of other human desires or actions, but the direct result of individual and group desires to spread the disease itself.

These attempts usually take the form of deliberate biting attacks of infected individuals on others; the infected saliva of a human bite usually enough to infect a host. Scratches, abrasions, and skin breaking wounds are also a problem; like other forms of rabies, rabies evangel can be communicated through scratches, bites or injuries that are quite hard to detect, a fact that sadly sealed the fate of one entire Atlanta Metropolitan Police Precinct station responding to one of the earliest riots of infected crowds.

As a virus present in the saliva, some kinds sexual contact may also spread the disease and this is now believed to have played a much larger role in the original development of the disease than previously thought.

More complex technological attempts on the part of infected individuals to spread the disease have been reported, from infection bearing syringes to bullets. Fortunately, however, these attempts to weaponize rabies evangel have been comparatively crude in terms of their delivery; like other strains of rabies, rabies evangel requires a cool, dark place to survive outside of a host.

The possibility of more efficient and devastating means of dispersal should not be overlooked, however, as rabies, despite not having the ideal characteristics of a biological weapon[2], has been considered in the past as a possible candidate for such a program. In this light, it is particularly hoped that more immunologists, microbiologists and medical health professionals do not become infected with rabies evangel and become recruited to the cause of spreading the disease.

Various human and religious groups have been by no means universal in their interpretation of the euphoria, schizoid ideation and hallucinations created by REV; this has led, in many places already divided by sectarian lines, to armed conflict. Again, from the perspective of the disease, this is a favorable condition and its inadvertent capacity to inspire organized conflict can be looked upon as another positive trait, as the collapse of social order, widespread chaos and injuries with broken skin, malnourishment, unavailability of medical services and large movements of people are ideal conditions for the spread of any disease.

Mortality/Morbidity

Rabies evangel has a very low mortality rate particularly compared to classical rabies, which uniformly fatal if not treated with vaccine.

However, once the virus has entered the brain and neurological symptoms appear, there may be no way to effectively clear the patient of the virus.

Worst of all, at this point, most infected individuals actively resist any treatment and deny having any disease, or that their hallucinations and euphoria are an illness at all; as with many familiar behavioral diseases like alcoholism or substance abuse, the denial of the problem on the part of the patient makes the disease utterly intractable to treatment.

Natural History

Many pathogens modify their host’s behavior to some degree to facilitate their spread, from the familiar nasal discharge and sneezing induced by the common rhinovirus to the biting behavior typical of animals infected with classical rabies.Rabies evangel would, at first, seem to be unique in the degree of behavior modification, but even more extreme cases are familiar to the world of pathology:

Even if we can accept the extraordinary mechanism that rabies evangel seems to exhibit, the question still remains: how did this pathogen evolve? Analysis of the virus’ genome indicates that it is a recent descendent of rabies. Yet, from our study of the evolution of other pathogens, we know that several things must take place in order for a disease to pass from a stage 4 disease still dependent on a sylvatic cycle, to one that passes exclusively from human to human (stage 5) as rabies Evangel has become (Wolfe, 2007).

To begin, there is the question of how humans could have started to come into regular contact with the original carriers of rabies, believed in this case to be bats.Investigative teams from the CDC dispatched to the first outbreaks of the disease in the American South believe that rabies evangel evolved from an asymptomatic rabies strain endemic to cave bats in rural Tennessee. It is believed that humans began to have regular contact with these bats when a particular extreme religious community took to the caves of Tennessee, in imitation of Mithraeum typical of early Christian practices of the first century, CE.

Living in close contact with infected bats for decades may have eventually allowed rabies evangel to accommodate itself to its human hosts. It is not known how the original strain of asymptomatic rabies evolved in the carrier bats.

In the remote rural areas of Tennessee many of the symptoms of rabies evangel would have gone unnoticed among similar isolated rural religious communities, where the behavior associated with rabies evangel (ecstatic experiences, glossolalia, seizures) would not have been unusual.

However, this would not, in itself, account for how the disease could become primarily a disease transmitted from human to human, let alone deliberately.Investigators speculate the virus became more aggressive upon the contact of these formerly isolated human groups with new urban populations that began to invade these formerly remote and rural areas of Tennessee as part of the urbanization and migration of large groups to the South as part of a general trend of development of the Southern United States. As contacts between the groups grew, the increasing frequency of human bites and other attacks as well as sexual contact may have given the virus the large sustaining infectious population it needed to develop into a purely human disease.

Other investigative teams from the WHO posit the origin of the disease to have been in bats native to the ancient caves of the Middle East; cases of the occurrence of the disease, however only appear in the Middle East long after the disease had already attracted some attention in the American South. Some investigators originally suggested that rabies evangel may even be an ancient human disease, or some descendent thereof, but this does not seem borne out by the genetic record and what is known of its history.

Conclusion

Though unfortunately, the human history of biological warfare is full of examples of deliberate attempts to infect others, rabies evangel is unique in that it is the first disease known to man that infected individuals have deliberately chosen to spread for the perceived benefit of mankind.

As such, we could say, as a manner of speaking, that not only does rabies evangel, like many pathogens, know a lot about immunology, but, if successfully weaponized, it is even capable of using what we know against us.

This is, of course, not literally true; REV itself is not believed to actually causes these complex behaviors; instead, it simply at most, predisposes the afflicted to these behaviors and at least seems to map onto preexisting existing beliefs structures in many infected individuals. Human infection remains a matter of choice: uninfected individuals may be induced or compelled to voluntarily become infected.

What success we humans have had in controlling disease originates from two of our most notable and seemingly exceptional capacities: our ability to discover and understand the nature of disease and treat or prevent it and, even more critically, our ability to organize ourselves in large groups, as nations, or even a species, to contain or eradicate such diseases. Only in this manner was our singular great success over a pathogen made possible: smallpox.

With REV we are faced with the perhaps fatal prospect that these very resources –our understanding of disease and ability to organize –are turned against us with the threat of REV. As a result, the long term prospects to contain this disease do not seem great, for as humanity becomes infected it will no longer wish to see it contained. Religion, like the love and war it has so often inspired in men, gets its force, its meaning, because it is a form of human solidarity. The ultimate fate of this disease may well be to become completely endemic to humans and so face eradication by redefinition; future authors of these bulletins will simply no longer consider it a disease.

In the meantime, we can continue to hope what human hopes we can have, uninfected by REV, still free to consider as to whether or not the disease is more aptly named “evangel”, the bringer of good news, or “dysangel,” the bringer of ill-tidings, and choose whether or not to accept the message it brings.